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F0637
D

Failure to Complete MDS SCSA After Hospice Enrollment

Barco, North Carolina Survey Completed on 12-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice care. The resident, who had a diagnosis of heart failure, was enrolled in the hospice program at the facility, as documented on a Long-Term Care Status Form. Despite this significant change in condition, there was no evidence in the medical record that an MDS SCSA was completed. During interviews, the MDS nurse confirmed responsibility for completing the assessment and acknowledged that it was missed, without being able to provide a reason for the oversight. The facility administrator also confirmed that an SCSA should have been completed when the resident began receiving hospice services.

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